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Complaint Investigation

Village Health Care Center

February 24, 2026 · Broken Arrow, OK · 1709 South Main
Citations 3
CMS Rating 1/5
Beds 90
Provider ID 375171
Healthcare Facility
Village Health Care Center
Broken Arrow, OK  ·  View full profile →
Inspection Summary

Village Health Care Center in Broken Arrow, OK — inspection on February 24, 2026.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0638
Resident Assessment and Care Planning Deficiencies

sampled residents reviewed for quarterly assessments.

The DON identified 49 residents resided in the

Resident #1, a discharge with return anticipated dated 11/06/25 for Resident #1, and an entry dated 11/19/25 for Resident #1.

There were no documented assessments since the admission assessment on 09/28/25. On 02/23/26 at 1:55 p.m., LPN #2 stated they were the second and most recently hired nurse to perform MDS assessments and care plans while the MDS coordinator was on leave. LPN #2 stated they were not aware Resident #1's quarterly MDS was due.On 02/23/26 at 2:15 p.m., the DON stated the quarterly assessment for Resident #1 was late due to the interim MDS nurse not performing their duties.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

375171 02/24/2026

Village Health Care Center 1709 South Main Broken Arrow, OK 74012

reviewed, and revised by a team of health professionals.

sampled residents reviewed for their plan of care for elopement.

The DON identified 49 residents

elopement.

The care plan for elopement did not show it was reviewed or updated after elopements on 10/15/25, 11/06/25, 01/16/26, 02/08/26, or 02/09/26.On 02/19/26 at 5:38 p.m., LPN #1 reviewed the care plan for elopement and stated the interventions were not updated since the care plan for elopement was developed. On 02/23/26 at 1:55 p.m., LPN #2 stated they thought the DON had recently updated the care plan for elopement. On 02/23/26 at 2:15 p.m., the DON stated the care plan for Resident #1 was not updated due to the interim MDS nurse not performing their duties.

375171 02/24/2026

Village Health Care Center 1709 South Main Broken Arrow, OK 74012

on every 15 minute checks for an indefinite period of time. An incident note for Resident #1, dated

jeopardy to resident health or #1 asked for medication that was unavailable and to go for a walk.

The incident note showed the CMA safety informed Resident #1 the medication was not due yet and they were busy and unable to go with the resident on a supervised walk.

The incident note showed Resident #1 informed the CMA they would

the building at 5:00 p.m.A state reportable incident report for Resident #1, dated 02/09/26, showed the resident requested medications that were not scheduled to give and was informed they would have to wait for the medication. Resident #1 requested a supervised walk outside and was denied by staff due to the staff member's responsibilities during resident mealtime. Resident #1 stated they would walk alone.

The report showed the facility was unaware of Resident #1's elopement for 30 minutes.

The family found the resident approximately one mile away at a local business and escorted the resident back to the facility.

The report showed the facility initiated every 15 minute observation of Resident #1 for an indefinite period of time as an intervention.A nurse's progress note for Resident #1, dated 02/11/26, showed the burn wounds Resident #1 inflicted on themselves were healed.On 02/19/26 at 5:38 p.m., LPN #1 stated Resident #1 was pretty independent but needed supervision.

LPN #1 stated Resident #1 liked to leave the facility without telling anyone which was ok when the resident was their own POA but now the resident was not their own POA and could not leave the facility. LPN #1 stated as one of the interventions, they performed every 15 minute checks on the resident, which started when the resident returned from their second elopement in two days. LPN #1 stated Resident #1 had a history of illicit drug use, and the resident exhibited drug seeking behaviors in the facility. LPN #1 stated what often triggered the resident's behavior was not getting medications when they wanted them. LPN #1 stated the resident would get angry and demand medications they could not have yet. LPN #1 stated having a staff member walk outside with the resident often helped.

LPN #1 stated other things that helped included listening to music in the common area. LPN #1 stated if Resident #1 was too upset, the resident would call for an ambulance or just get up and walk away from the facility. On 02/19/26 at 5:55 p.m., the DON stated they did not investigate the elopements to determine the root cause of each elopement.

The DON stated they did look at the cameras to see when and how the resident eloped.

The DON stated the resident did not always exit through the front door and on 01/16/26, was observed on camera to watch the activity around a back door for a time before exiting through the back door.

The DON stated when they asked the staff when the resident was last seen, the staff reported it had been 10-20 minutes earlier during the administration of a medication, but when they reviewed the camera footage, the medication was administered an hour earlier.

The DON stated that was the date the resident purposely burned themselves with a lighter.

The DON stated the police report for the elopement on 02/08/26 identified the residence Resident #1 was found in was a known drug house.

The DON reviewed documentation for observation of the resident every 15 minutes.

The DON stated the intervention to observe the resident every 15 minutes did not seem to be an effective intervention.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Broken Arrow, OK, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Village Health Care Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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